With any luck you may never encounter such a scene. Remember the original article was discussing a combat situation, with blast injuries from IEDs as a prominent part of the picture.

Civilian settings are a little different. I have seen a lot of fractures, mostly from falls, and precious few, if any, blast injuries. I've never had to use a tourniquet, although my training has always included them as a potential tool in extreme situations. Most of my experience has been in backwoods conditions. I suppose injuries in vehicle accidents might be a little closer to the combat spectrum.

Agreed, and even if the injury is more severe I wouldn't be treating any injuries under combat conditions. Stick to the basics: call 911, evaluate scene, approach safely, consent to treat victims, c-spine immobilization, stop bleeding, treat for shock, wait for the cavalry, which will be arriving directly.

Deaths are generally classified in 3 sometimes 4 groups when it comes to TCCC (Tactical Combat Casualty Care):

1-Non-preventable death on the battlefield, meaning that no matter what medical interventions were made immediately after injury the patient would have died. Examples: complete transection of the thorax, decapition or massive open head wounds.

2-Preventable deaths on the battlefield, meaning that the patient/soldier/etc could have reasonably been saved with combat level interventions applied appropriately immediately after injury. Examples: arterial bleeding stopped by a tourniquet, occluded airway fixed by either positioning, nasal airway, tracheal airway (ET tube, King airway, or other), or surgical cric, decompression or a tension pneumothorax. Those three are the leading causes of preventable death on the battlefield at this time.

3-Non-preventable deaths due to injuries incurred on the battlefield, meaning injuries that were so severe that even with extensive capabilities being available or applied either at battalion aid stations or forward surgical teams they still die, just not on the battlefield. Examples: severe head injuries, massive internal injuries to essential organs (heart, lungs, liver being the leaders).

4-Preventable deaths due to injuries incurred on the battlefield, meaning that the patient/soldier could have lived had steps been taken throughout the spectrum of care after the care under fire phase. Examples being antibiotic therapy, surgical procedures, etc.

On a separate note:

Tourniquets should not be a tool of last resort. Assigning it that title means that you will use other steps first even when you know that a tourniquet is appropriate. Tourniquets are tools just like any other item in medicine and just as I wouldnt use a tongue depressor to splint a broken leg, it is misguided to recommend against using a tourniquet as a first line intervention in an obvious arterial bleed in an extremity. Being realistic in your training and understanding when and when NOT to use a tourniquet will keep you on the right path. If the bleed is squirting and not just dripping or oozing you can try with a single pad/gauze/etc and pressure to stop it, should that fail you need to go immediately to a TQ. Particularly in a remote environment where literally every drop of blood is priceless and it will be a good bit of time before you can replace it.

As a combat medic for a security team in Iraq I used tourniquets for any extremity squirters. As a civilian Paramedic in the states my protocol is to apply pressure with a gauze pad and failing that transition to a tourniquet. Many people have died relearning these lessons and I hope we dont soon forget them again.


Some pointers on TQ use:

-Use a premanufactured device, I recommend the SOFT-T, SWAT TQ, and TK4/TK4L based on my experience and testing. Belts dont work as well as you would think. I literally just ran a gun shot wound call where a guy had shot himself in the leg and tried to use a belt as a tourniquet. For one, he didnt need a tourniquet and for two, it was completely ineffective at applying pressure. The TK4 costs less than $10 and weighs less than 2oz.
-Know how to use it, that means get a couple and dedicate one to training and practice applying it with your strong hand and weak hand on all extremities.
-Dedicate one to training, many after action reports (AARs) from the military revealed early failures of TQs and it was found that this was due to people repeatedly using them in training and then putting them on their gear for operational use. They were not designed for this as they are single operational use items. So dont set yourself up for failure.
-Get training on when and when NOT to use it. As good as online forums are they are no replacement for hands on, structured training from a professional.

I know that was kind of long winded but hopefully that will answer some questions.

Mike

Good info, MikeG. It matches up with what TCCC was teaching a few months back.

IMO, given that most here aren't going to be messing around with IV fluids and making decisions on blood transfusions the effective take-away, the lesson that can be put to practical use, is to apply tourniquet/s early. If the bleeding from a wound isn't obviously insignificant you skip the direct-pressure and pressure point steps taught thirty years ago and apply a tourniquet. When things slow down you come back and reevaluate.

It is simple enough, but often quite painful, to remove a tourniquet that was installed where it wasn't needed. Putting blood lost back in is a much harder trick.

The turnaround on tourniquets is so complete that they are included in NREMT test sheets for hemorrhage.

Some still recoil at the thought of using a tourniquet for any reason. Want to know how a surgeon works on a pt's hand or foot? They apply a pneumatic tourniquet, stop all blood flow to the extremity for 2 to 4 hours, do their work, then remove the tourniquet. Happens every day in hospitals all over the country.

Two additional things to keep in mind:

-Although it's common practice to place the tourniquet just above the source of bleeding, it isn't always effective due to the fact that there are two bones located between the wrist and the elbow, potentially preventing sufficient pressure on the artery to stop the bleeding (the same is obviously true with the lower legs). In these cases it is often necessary to place the TQ higher up the extremity where it can compress against a single bone and stop the arterial bleeding.

-Once you install a TQ, do not remove it for any reason. Although anyone can install a TQ, only a trained medical professional should remove it. High concentrations of lactate and hypoxanthine build up in the tissue below the TQ, which if quickly released into the bloodstream upon TQ removal could cause serious medical complications, including shock.

Jim

This article addresses Preventable Deaths. In general terms 80 % of combat casualties die on the battlefield. The remaining 20% can be termed Preventable Deaths if the militaries version of the ABC’s are initiated in time. Combat Lifesavers are taught to aggressively treat hemorrhage on extremities using tourniquets, Combat Gauze, and Israeli pressure bandages. They are also taught how to manage the airway, using a nasopharyngeal airway (NPA), and treating penetrating chest injuries using occlusive dressings, wrapper from combat dressing and tape, along with relieving tension pneumothoraxs by inserting a 14Ga catheter in the second intercostals space on the injures side. It is not practical to perform CPR on the under fire. The Army IFAK contains all the materials necessary to treat the above listed injuries.

Cheers,
W-W

It's interesting how the tone of the discussion here on ETS around things like tourniquet use has changed. The last time we discussed this same topic of advances in military medicine--maybe a couple years ago--was rather more cautious in tone about turniquet use, from what I remember, particularly about applying them in the civillian setting.

Was it Polak187 who was mentioning that many former medics who went into EMS after getting out were often too quick to jump to the tourniquet when direct pressure would have been sufficient?

Just like advancements in auto racing often filter down to passenger cars, so too can advancements in military medicine, but they're not the same situations, so it's going to take time to figure out what to keep and what to discard from all the recent combat experience.

I'm glad medical treatment and training now incorporates tourniquets, but for most of us this isn't a huge change - unless we are battlefield medics or active EMS, we just don't see many arterial bleeds. We still see 95% bleeding that can and should be treated by pressure. But if I see uninterrupted arterial bleeding, I'll reach for my Bloodstopper 2000 kit with the TQ and apply that. Its always good to have other options.

There is the possibility of a pendulum shift, that with broader acceptance of TQ use some wahoos out there may apply unnecessary or unsafe tourniquets. That can only come from folks who aren't trained or experienced.